Post on 12-Jul-2020
DISAPPEARING NAIL
BEDTracey C. Vlahovic, DPM FFPM RCPS (Glasg)
Clinical Associate Professor, Temple University
School of Podiatric Medicine,
Philadelphia, PA
A patient presents with complaint of…
• Ingrown toenail at the
tip of the toe
• Has had multiple nail
avulsions to treat nail
fungus which has
never seemed to
solve the problem
• The length of the left
hallux nail is not the
same as the right,
which is bothersome
to the patient
Comparison of Right vs Left
Physical Exam and Lab Results
• Pain on palpation at the distal tip of the nail
• No pain on palpation of the medial or lateral corners or on
the nail plate itself
• No drainage, no edema of the lateral nail folds
• Distal hypertrophy of the pulp of the hallux
• In office KOH, no hyphae present
• What’s next?
Radiographs collimated to great toe
What are your thoughts?
A. Dermatophyte infection--KOH isn’t that sensitive
B. Subungual exostosis that is cartilaginous in nature and
you can’t see on plain films
C. Trauma—it’s her narrow toebox causing the nail to look
like this
D. Too bad for you, lady, bad things happen to good nails
and you’re just going to have to deal with it
E. It doesn’t matter, I will just remove the nail again
F. Disappearing nail bed is the cause and I have to
discuss this with the patient
Disappearing Nail Bed• Coined in 2005 by Dr Daniel (Cutis 2005;76:325–327)
• A shortened or narrowed nail bed that is the result of long
standing onycholysis
• 20% shorter than the bilateral nail
• Long standing onycholysis can cause epithelialization to
occur and dermatoglyphics to appear
• May occur on fingernails (onychophagia) or toenails
(hallux most common)
What can cause it?
• Onychomycosis
• Onychogryphosis
• Trauma (blunt force or repetitive)
• Nail Surgery (ie iatrogenic)
• Biomechanics (ie hallux extensus)
• Other disorders that cause nail onycholysis: ie psoriasis, lichen planus, medications
• You do want to rule out subungual exostosis or other boney deformity first
Daniel et al Skin Appendage Disord 2017;3:15–17
Why?
• Normal nail bed lacks a granular layer of the epithelium
and is 2-3 layers thick with a hearty vascular and nerve
supply. The nail plate is the “stratum corneum” layer for
the nail bed
• As it grows forward, Nail plate slides over the nail bed.
There is a thin attachment called the bed epithelium
• Nail bed with no nail plate covering it seems to have
digital fingerprint memory—ie the nail bed becomes like
the distal tip of your toe. The nail plate can no longer
slide across the nail bed.
Why? Cont’d
• The distal pulp of toe deforms, creating a physical barrier
for the nail to grow forward
• Unknown how long onycholysis needs to be present for
this to occur
• Anecdotally, I have noticed a grossly atrophied nail matrix
upon removal of these nails
What are our options?
• Doing a total nail avulsion will NOT solve this issue
• Once epithelialization has occurred, the nail plate and nail
bed will never adhere
• If the nail can grow forward, there will be a cavern
underneath the nail and discoloration
• Must create realistic expectations with patient!
How do we manage?
• Conservative options:
• “Tape” the distal skin (Omnifix)
• Treat the ingrown nail
• Camouflage with Keryflex (ie cosmetic)
• Wear shoes that accommodate the deformity
• Treat dermatophyte, but set patient expectations
Taping method b/l
Keryflex Nail Restoration
Before After
From Keryflex.com
How do we manage? Cont’d
• Surgical options:
• Remove wedge of skin distally and advance skin distal
• If subungual exostosis or hallux extensus present,
account for that
• Gingival graft to recreate nail bed??
The wedge excision I have done
Final thoughts…
Thank you! traceyv@temple.edu